New Clients
Thank you for choosing Carlock & Associates.


PLEASE NOTE: We do not accept credit cards. Your copay in cash or by check is due at the time of service or there is an additional $10 charge.

 You will need to print the following forms, fill them out, sign them, and bring them with you to your first appointment. You will need Adobe Acrobat Reader to view these client packs. If you do not have it, you can download it for free at www.adobe.com

For Adults:  UBH has mandated that every client entering treatment be requested to complete a Wellness Inventory as part of the initial evaluation and treatment planning process.  UBH will send you a follow-up assessment six months after your initial visit to check progress.  You do have the right to opt out of this if you choose, but you must indicate this on the last page of the form. 

UBH CLIENTS MUST DOWNLOAD BOTH ADULT FORMS (#1 and #2, below); ALL 0THER CLIENTS, PLEASE DOWNLOAD FORMS UNDER #2.

1.    UBH Clients over age 18- click here for the UBH Alert Wellness            Assessment Form

2.    ALL Clients (including UBH) over age 18 - download forms here.
Please print out all forms and fill out everything in its entirety.

For couples/marital you will need to print out two copies of the "Client Data Form" and "Personal Information Form;" one for each of you to fill out. Print out only one copy of the remainder of the client pack.

For Children and Adolescents:  UBH has mandated that every client entering treatment be requested to complete a Wellness Inventory as part of the initial evaluation and treatment planning process.  In the case of patients who are minors (exept for minors who are emancipated or able to consent for their own treatment under the laws of Ohio), the parent or guardian should be asked to complete the assessment.  UBH will send you a follow-up assessment six months after your initial visit to check progress.  You do have the right to opt out of this if you choose, but most indicate so on the last page of the form.

UBH CLIENTS MUST DOWNLOAD BOTH CHILD FORMS (#1 and #2, below); ALL OTHER CLIENTS, PLEASE DOWNLOAD FORMS UNDER #2.

1.    UBH Clients under the age 18- click here for the UBH Alert Wellness Assessment Form.

2.    ALL Clients (including UBH) under the age 18 - download forms here. Please print out all forms and fill out everything in its entirety.
 

Parent or Guardian: Please fill out all forms with the child/adolescent's information (i.e. name, birthdate, social security number) but sign your name. Have the adolescent (age 12 or older) fill out the Adolescent History form about him/herself. If the client is under age 12, please disregard the Adolescent History form.

Directions to both the Dayton and Vandalia offices are included in the client packet, as well as a form listing our fees.

 

Please make note of the NO SHOW and LATE CANCELLATION fees on that page. If you need to cancel an appointment, we require 24-hours advance notice. If you give less than 24-hours notice, you will be charged for the full fee of the session, because we cannot file this with your insurance. If you fail to show for your appointment, you will also be responsible for the full fee of the session.  We do have voicemail available 24/7.